on meniscus tears. So Seth, do you want to introduce our panelists? Sure, so I'm very happy to be here. Thank you to everyone in the audience, both Anna and Issakas for one, facilitating my victory. So now I'm in a good mood here on the panel and really want to recognize some thought leaders from around the country and world here. So we have, is Eric here? We have Nick Scaglione, who's here just to my side. We have Kyle Martin, who's here as well, Ryosuke Kuroda, John Lane, and Pat Smith. We have great cases, a lot of good discussion ahead. We have 18 minutes. I want to remind the panelists, this is rapid fire, so say what you mean, mean what you say, don't pontificate. And Brian, you can do case one, bud. And no additional images, don't ask esoteric questions. All right, let's keep it by the book. So this is our first case. It's an 18-year-old offensive lineman. He's a collegiate freshman. He comes in five-month history of knee injury that's just been limping along. You can see he's a stout young lad, 5'9", 270. He's got one plus effusion, tenor palpation laterally. He's got a positive McMurray, some slight symmetric valgus, and definitely some rotational abnormalities. But otherwise, mechanically stable knee. Here is imaging. And so I'd call attention to you on the lateral compartment here. John, what do you see there? If you could go back through it, but it looks like he's got a macerated type of tear in the radial tear. Where is it? Yeah, he's kind of got a little bit of a ghost sign there and certainly a mid-radial tear on the lateral side. I'm sorry, it's a little bit jumpy on the imaging. But it looks like it extends all the way to the periphery and definitely got some bone marrow edema. Kyle, what do you think about this? What are you doing with this in your hands? How are you counseling this patient? Yeah, I'm gonna be laying a lot of crepe. I'm a little worried because he's got valgus malalignment and a radial tear, making that lateral meniscus basically non-functional. So this is a meniscus repair and potentially an osteotomy, depending on how much valgus he's in. Pat, he says, I wanna finish up my season. I'm in Missouri. Get me back, coach. What do you tell him? Is he allowed to go back in a brace? What's your recommendation to him and his mom that he says, do what you want? Terrible actor from years of taking care of football players. You gotta fix this radial tear. If you let him play, he's gonna deteriorate his articular cartilage right away. I fix these at all costs. You take this out, it'll end his career eventually pretty quickly. So for me, this would be a meniscus repair as soon as I could. Yeah, and full disclosure, he goes and does exactly that. He goes back to play, finishes his season, come back, and you definitely see some agonal breaths from the distal femoral cartilage there. But you can see it's a very subtle radial tear. Dr. Correta, what are you doing for this? What's your approach? Yeah, we need to repair the rather meniscus. We do a horizontal suture. And we, in Japan, we do a tie grip suture to more strong suture for the inside-out technique. And also, we check the alignment. It's a pretty valgus alignment. We need to maybe additional closed ridge, femoral closed ridge osteotomy. Yeah, for those that are unfamiliar, Dr. Scaglione, can you talk a little bit about the tie grip or hashtag configuration and how you might utilize that for this type of tear pattern? Yeah, so what you have is an opportunity here with sort of a full array of tools to create a crossover stitch and then a ripstop stitch. So it's essentially a hybridized approach. And you can do that both with the inside-out but also all arthroscopic suture passers, some of the new proprietary suture passers, which allow you to really be very versatile in terms of placing the stitch. And then the biomechanical profiles now have been published to show that it does make a difference, especially in these. These see significant compressive forces which want to essentially distract the coaptation. Brian, can we have a quick panel? Raise of hands. Who's doing this inside-out? Who's doing this all inside? So maybe inside-out? Okay, and all inside? What's this? How about outside-in? How about from the audience? Both. Yeah. Yeah, this looked like anterior horn body junction. So I like, if that's the location as it seemed, I would do outside-in. Thank you. Yeah, good suggestion. And you can see we've got as many bridging stitches as that meniscus can hold. And you can see final tensioning. I'm definitely, to quote JK, hog-tying that a little bit in order to over-tighten it under the anticipation that 270 pounds of load may lead to some sequential loosening over time. So we do the full setup of six weeks of limited weight bearing. We have tried to allow him to get into an offloader knee brace. Quick question about rehab. How are you all taking it? Are you doing full weight bearing? Can I get a show of hands? Immediate full weight bearing in a brace? Toe-touch weight bearing? Partial weight bearing? That was a non-weight bearing. Non. Non. So full non-weight bearing. And that's for us. It was for six weeks. Who's using biologic adjuncts for this tear? Show of hands. Does the knee pick count as a biologic adjunct? We'll allow it. All right, perfect. You can see that's what we've done here. Quick plug for the MVP trial, which is going to be a comparison of notch stimulation versus a biologic adjunct. When would you allow him to return to play? Kyle? No sooner than six months, most likely. Yeah. Yeah, so pretty consistent. Anybody sooner? All right, I'll pass it on to you, Seth. All right, so these will be fairly straightforward cases. 21-year-old male. He has an isolated ACL on his MRI and an explosive grade 3 pivot shift. You can see range of motion parameters, borderline elevated tibial slope. So Kyle, what's the diagnosis here? And why and how often do you think we're missing this on MRI? Yeah, so this is a posterior horn meniscus root avulsion. It looks like the meniscus femoral ligament is still intact. I think the MRIs are maybe getting better. We're looking for them, but we're still missing a lot of them. I see this very commonly with ACL injuries interoperatively. Pat, what do you think the incidence of missed lateral roots in ACLs are these days? Yeah, I think it's fairly high. And I think you really feel it when you go and do revisions. Commonly, this is a biomechanical. You know the root is very important for rotational stability. And I think one of the reasons for failure is they're missed. So I think it's really critical to really probe that meniscus in your primaries to make sure you don't have any separation there. John Lane, when you see this in your OR, talk to us about the preparation for it because these can be missed. I think Bruce Levy told me up to 2 3rd of his recent series was missed, actually. My understanding was 1 3rd prior. But you have your root stuff ready to go on all ACL primaries. And tell me about how you avoid your ACL and kind of order of operations here, if you would. Yes, I think it's really important to look for these before you start the ACL surgery. And I try to put my tunnels in for the ACL. And then I work around where I think the best position is for these tunnels. I use just a single tunnel. Nick, where do you think is the best location for you to drill your root tunnel in relation to your ACL tunnel? So it's the lateral root. So tell us exactly where you think that guide should go to make it super slick. I think it's a little bit easier on the lateral. So traditionally, I'll drill through the lateral side. Again, this is a very small drill tunnel. But, and you mentioned it, what I'm really excited about is the ability now to get aperture fixation with some of the new proprietary knotless suture anchors. So it basically takes that out of the game. So you don't even have to worry about the tunnels. But traditionally, you're posterior and you're coming in from a different vector. Yeah, I'm typically coming in from medial and having my aperture kind of posterior medial to my ACL tunnel, which is more proximal and central. And then Bobby Marks, maybe talk to us about, I'm gonna just go here. This is beautiful work from Aaron Critch just showing his technique. We went through it in the last session. Anything different about using suture tapes or using locking loops or using simple stitches, leader stitches, one or two tunnels? Like what are the technical pearls here that lead you to success? So I generally err on the side of doing less unless I think there's an important reason to do more. And so in this case, I'm using a single luggage tag and a single tunnel because I, you know, I mean, I don't think there's good clinical evidence certainly to suggest that more than that is necessary. And I haven't had any problems with that. So I haven't changed. Anyone doing anything major and anything different? Go ahead. Yeah, I use a modified Mason-Allen configuration. We just got a study coming out showing compared to cinch and two simple sutures that the modified Mason-Allen basically a rip stop. And it's really pretty convenient with that new proprietary advice that was just described. You're able to do it knotless. So I'll do this, you know, horizontal mattress and then I'll put in a simple over the top and hopefully that's gonna make for better healing. Dr. Kuroda, across the world, anyone doing suture anchors for these roots on the lateral and medial? I know we do, same, same process. Same as this? Yeah. Okay, excellent. And I think we've covered the rehab on that. Let's move on to the same kind of patient. And now we're looking posterior medial and the MRI, you know, also was vague. And so what are we looking at here? Maybe Kyle, what are we seeing here? Got a ramp lesion of the medial meniscus there. Okay, and so again, what's the range here, John Lane, you think on incidents? How often are you seeing this and how often do you think you're actually treating this? I think people are not appreciating as much because people aren't going through the notch. I think it's harder to diagnose on MRI, at least in the way that they're read. And so I think it's important to look through the notch if there's any suspicion of that. Nick, are you going to look in the back every time and what on MRI is gonna raise your flag? And obviously the clinical, we've talked about explosive pivot. Yeah, so second question first, the MRI will not always tell you and it has to do with displacement. Now this is a displaceable ramp, but the answer to the first question is we teach residents on every single case to go back and look in the back, modified Gilquist and look at the PCL just for practice. And then you won't miss it. But if you don't do that, you will with both the MRI and lack of clinical check, you will miss these. Now that posterior tibial edema medial can tip you off as can the right patient, but I agree completely. Does everyone look in the back? Does anyone not do it routinely? So you do it selectively based on suspicion, right? What about a pie crusting? Is anybody utilizing that to get a better view of that meniscal capsular junction? And do you have any pearls that you might share on that? Anybody from the panel? I'll just say real quick. I think the ones you can't get in and doing it on everyone, not say don't say always all the time, but doing it on everyone are the arthritic knees. So, but on these cases, you usually can get in and look and I don't see an indication to pie crust, at least for the ramp, maybe on some of your posterior medial roots. And then use a spinal needle. It's a one centimeter off the medial epicondyle, two centimeters back. And it's just a single portal in valgus and you'll get it to stretch. So raise your hand if you pie crust the femur. When you pie crust? Yes. Raise your hand if you pie crust mid MCL. And what about distal on the tibia? Okay. And Kyle, talk me through kind of technique now for ramp. So I'm just gonna show a couple of videos for interest of time while we do this. So this is the approach going from the back with a lasso bringing the capsule back to the meniscus base. We'll also show an all inside technique from the front. And so what's your thought process on the differences between these two? I think it really depends on the configuration. Sometimes you get the hidden tears that are underneath where you look from the notch and it looks actually totally normal when you look down. And so you kind of have to have all the tools in your armamentarium. So all inside devices are pretty good for some of these. If it's a small posterior horn ramp, this is a great technique using a lasso or other device to pass a stitch and then tie it. Inside out also works if it extends a little more medially. So just be comfortable I'd say with everything and know the options have everything available. Does anyone do all inside technique like showed here by Al Gikud? Go ahead. So why do you think this works versus the other? I think it's six and one half does the other. I think it's displacement. It's just, you have to do, if you do this, you have to basically be able to try to get a vertical mattress and it's about the cadence and configuration. Whatever works for you. I think you can make it work. So first one coming above the meniscus, then it'll actually come below the meniscus and also have excellent access to look from the middle and in the compartment. So pie crusting for this type of situation is probably critical if you're gonna do it from the front. Yeah, I think the key on that first anchor, I think that first anchor went into the capsule. I would try to take a bite on both first and second anchor on the meniscus fragment. Pat, lastly, how do ramps change your ACL rehab if you don't have any other? It really doesn't. I don't think the weight bearing is quite as strong as say doing a root repair here. So for me, it's more about leg control. So I don't necessarily keep them on that way for more than just a usual couple of weeks. Does anybody change anything they do in range of motion weight bearing with an added ramp to an ACL reconstruction? I'd be maybe a little bit slower to weight bear inflection, but they can weight bear an extension right away. Go ahead, Brian. Yeah, so this is case three. This is a 43-year-old Asian female. This is from Monday. And so definitely tender to palpation, laterally full range of motion. Got a little bit of patellofemoral symptoms that definitely are corroborated on MRI. You can see some symmetric valgus. These are two images, coronal and sagittal. Dr. Corotta, what do you see here? I'll let that run through one more time. Hopefully, that'll loop through. Sorry for the contrast. Spomal oedema in the, which would be the medial side? Yeah, so a little bit of marrow oedema. Lateral side. Yeah, lateral femoral condyle. And you can see some noise and what appears to be some suggestion of a discoid meniscus. And so the threshold for action on this often is frank mechanical symptoms or instability. And in this individual, we did end up taking to arthroscopy. These are some of the images. And I will submit to you that sometimes it's not always easy to identify these somewhat unstable discoid incomplete meniscal variants. And so this is some of the assessment arthroscopically. Pat, how do you manage these? You can see some of these will have a tendency to have this enlarged popliteal hiatus. Maybe there's some popliteal fascicular involvement. Oftentimes, you can have fatigue failure at that far posterior horn. Do you have any pearls on how to assess for and make sure you're not missing these? Yeah, I think the one thing I've seen too is the root sometimes is almost off. So for me, sometimes what I've done in these is leave the body and I'll fix the root to try to stabilize them. Because doing a saucerization, it makes you feel a little better that it looks better, but still they seem to go on to DJD. So for me, I really focus on that root, approving that as well. Yeah. John, how would you manage this? I would try to find out where the instability was and I would use inside out technique to try to stabilize the most that I could. Yeah. Bob, anything you'd do different? I mean, this looks quite repairable at arthroscopy, but sometimes the MRI will show that it's clearly degenerative with signal throughout the meniscus. And if that is the case, I didn't quite appreciate it fully on the MRI, but if it is the case, then you're doing a two-stage meniscectomy by starting with the repair. So sometimes, if it always feels a little sad to cut out the meniscus, but sometimes it's the way to go if it's not gonna heal. But the MRI is helpful there. If you see a horizontal signal throughout, you know it's the chance of healing are remote. If you are repairing this, Nick, would you do adjunctive saucerization as well? Not necessarily. I think that, look, this is dysplasia. And so, and I think there, I agree with Bob. I think there's some breakdown in the tissue. But now that you're showing me, I agree that it should. Leading the witness. Saucerize it a little bit. The key, I just wanna say, is when you repair this, I love the inside out, is don't skewer the popatias. Go in front and back. Yeah, so I ended up doing a hay bale at the popatial hiatus, and then all inside on the top and bottom surface. Last one, do you wanna? I don't think we have time for that, but Bob, let me just follow up. So if you have that tear, you start trimming away, and you get into the horizontal component of it in this young person, you don't think that is fixable in circumferential compression? No, if there's some decent stuff back there you trim back to, and it's totally off the capsule, so you think there's some blood supply, it's okay to fix it. But, you know, sometimes when I have to pull out the biter, and I feel the resident or fellow are getting a little sad, I'll just say to them, we didn't tear the meniscus. We didn't tear it. The meniscus is torn, but it's not our fault. We didn't tear the meniscus. We're just here to cut it out. Emotional neutrality, I like it, yeah. And last on this topic, and then we'll close the session. Dr. Kuroda, a lot of these patients may start in varus, or symmetric varus, and if that meniscus is sick-looking, this may progress, so how do you follow them over time? Do you, if they're doing well, do you do alignment views? Do you take them back, or? Yeah, this type of meniscus, very often we see, so in the Asian population. So we sometimes do additional centralization, because those lateral meniscus is very extrusion, so socialization plus suture plus centralization, sometimes we need. Okay. Yeah. That's a cool technique. Any parting words, Seth? No, thank you very much for your attention, everybody, and it's been a great conference, thank you. Thank you. Thank you. So if we can, we'll pull up the next debate and call our two participants to the stage.

meniscus tears

diagnosis

surgical techniques

biomechanics

stability

optimal outcomes